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Dietary Services

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Importance

Good food is important in the treatment of patient & is a part of his total careAdequate nutrition during hospitalization enables the patient to recover earlyReduces the “average length of stay” of the patientEconomic and “cost effective” for the hospitalTakes home a good impression of the hospital if the food is good and attractive ie helps in developing good “Public Relation”.

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Goals of Dietary Services

Optimum nutrition to patientsMaintenance of morale of patients through good & attractive foodDietary advice to patientsAchievement of goals with maximum efficiency at a minimum costMaintaining good public relations by quality food service in hospital

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Food Service Systems

It is a facility where large quantities of food intended for individual service and consumption are routinely provided, completely prepared. This is regardless of consumption, premises or whether or not there is a charge of food service

Conventional system followed in most hospitals– Menu items are prepared in a kitchen, on the premises,

where the meals are prepared and are held in a short time and maintained either hot or cold until serving time

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Conventional Food Services System

Advantages– Quality Control- More adaptable to regional, ethnic &

individual preference

Disadvantages– Because of menu differences it gives a stressful workday.– Skilled workers may be assigned tasks that could be done by

non-skilled workers– Needs two shifts of employees

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Commissary (Central Production Kitchen)

It has a large central production kitchen with centralized food purchasing & delivery of prepared food of satellite units located in separate remote areas for final preparation and serviceAdvantages– Saves on economy because of bulk cooking– Quality control is better because it has only one unit to superviseDisadvantages– Poor food safety in distribution- contamination– Needs high level equipment for mass production.

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Ready Prepared (Cook & Chill)

Foods are prepared in advance & stored

Advantages– No peak period pressure– No delay in preparation

Disadvantages– Need for cold storage and freezers

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Assembly/Serve

Advantage– No investment on equipment & space – absolute apportion control

Disadvantages– Limited availability of menus – Quality Control

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Functions of Dietary Servicesin Hospital

Procurement, storage & accounting of food items in all its formsProcurement of physical plant & equipments for the department.Issue of rations for daily cooking Menu planning & recipe standardizationPreparation & cooking foodDistribution of foodPreparation of modified dietsDietary education to patientsTraining of dieticians and under graduate studentsAssisting in research on metabolic disorders

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Delivery & Service Goals

Maintain quality characteristics including desirable temperature of foodEnsure microbial safety of the food to the consumerPresent attractive food in appearanceSave steps and energyReduce labor time and costsLessen worker fatigue

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Delivery System

Centralized System (into trays)

– Better quality control– Better portion size– Less equipment

Decentralized System (to the pantry)

– Quick service– Better temp. control– More labor system

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Planning ConsiderationsAverage number of meals served per day Type of food distribution systemHospital policy concerning meals, location of cafeteriaSample menu which will be usedEnumeration of modified diets which would be prepared.Number of qualified dieticians & subordinates which will be required.Ear marked storage spaceDelivery schedule for perishablesHousekeeping policies for proper cleaning & space allocation of different types of suppliesWaste disposal policy

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Physical Facilities

Site– Located on the ground floor– Should be in a place where the noise and smell from kitchen

is not disturbing to patients– Less cross trafficking in the route of food transport

Layout– 50 sq ft/bed in a 50 bedded hospital– 15 sq ft/bed in a 500 bedded hospital - McGibony– 8-10 sq ft/bed in the recommended space - UK Modil– Floors of concrete or terrazzo for easy washing – Running Floor Drains

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Physical Facilities (contd)Reception of supplies– Receiving area should be located where noise of trucks will not disturb the

patients– Door should be wide (5 ft)– Preferable to have a platform scale in the entrance of receiving areaStorage– Area should be dry & well ventilated for canned & non-perishable foods– Sufficient to hold stock for 15 days– Refrigerator for poultry etc– Separate storage space for linen, equipments, dishes and gas cylinders

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Physical Facilities (contd)

Refrigerator– Walk in Refrigerator- Advantages are

• More space• Convenient for handling large containers• Accessible and permits more careful examination of its contents• Easy to clean

– Reach in Refrigerator– Under counter reach in

Refrigeration space of 1.5 cu.ft. per person is enough to provide refrigeration, including zero storage facilities for frozen food -MacGibony

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Physical Facilities (contd)

Food preparation area– A double sink with drain boards for washing, soaking, sorting

and cutting– Table area of 4 linear ft/worker– Non- veg & veg section ideally to be separated.

Special diet area– Should be located next to dietician’s room for effective control– Only minor cooking equipments are required here

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Physical Facilities (contd)

Formula Room– Adjacent to nursery– A bottle sterilizer, refrigerator & portable carrier to prepare

milk for babies

Serving Area– Two Systems

• Centralized• Decentralized

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Physical Facilities (contd)

Centralized Serving– Advantages

• Floor pantry is eliminated & therapy bed space is increased • No duplication of equipments• No duplication of personnel• Fewer mistakes in filling diet orders, trays more attractive• Food wastage can be checked• Better food distribution & reduced pilferage

– Disadvantages• More experienced personnel needed• Food becomes cold by the time tray reaches the patient• Not suitable for horizontal building

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Physical Facilities (contd)

Decentralized Serving– Advantage

• No need of trained personnel• Floor service enables the food to be served hot• Unused food returned in bulk to kitchen• Nurses receive a necessary part of their training in food servicing

– Disadvantage• Requires considerable space on each floor at the expense of patient care

area• Extra equipment on each floor• Extra staff needed• Lack of supervision leading to pilferage• Danger of contamination

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Physical Facilities (contd)Dining Room– Solution to curtail disadvantages of both the above food

distributions– Morale boosting for ambulatory patients– Increases interaction between patients & develops good relationsWashing Room– Requires 3 compartment sink

• One for pre rinse at 120° - 140° F temperature• One for washing at 120° - 140° F temperature• One for rinsing with water 180° F

– Facilities for sterilizing food containers of trolleys

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Physical Facilities (contd)

Doors & windows– Fly proof with 16 mesh wires/sq cm

Lighting– sufficient in working area

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Physical Facilities (contd)

Employees facilities– The employee who would prepare food should preferably take

a bath before doing so. Therefore, facilities should be available for the same.

– McGibony recommends• One locker for each employee• One washbasin for every 4 employees• One shower for every 8 employees• One toilet for every 8 employees

– Resting rooms for different categories of employees– Office for dieticians

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Standards

Joint Commission on Accreditation has laid minimum standards for – Organisation– Facilities– Personnel– Food handling practices– Records– Policies

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Standards (contd)

American Dietetic Association has laid standards for – Education of dietetic interns– Specified standard educational qualification for

qualified dieticians

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Organization

Number of staff is determined by– Average number of patients in wards– Number of modified diet– Type of service– Number of personnel served– Extent of educational programs– Physical capacity of Dept

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Responsibilities of Director Food Services

Plans, directs and coordinates activitiesEstablishes departmental regulations and SOPRecruitment and selection of staff.Selection, promotion and transfer of staffReviews records and reports on diet, cost & inventoryDelegates authority for smooth functioning Attends meetings and conferences to keep abreast with new knowledge

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Suggested Staff Structure (DGHS)– 300 to 600 Beds

Dietician

Catering OfficerAsstt. Dietician

Store Keeper Steward

Asstt. Store Keeper Cooks

Cook Mates Cooks

Cook Mates

Therapeutic Diets

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Policies

General – Dietician is the head of department– Department must operate 16 hours per day– Work schedule to be planned– Fixed service timings– Fixed charges to be levied– Dietician to supervise all activities in kitchen– She visits patients for making daily diet chart & opinions as

well

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Policies (contd)

Food Purchase– Dietician is responsible – Spot buying & seasonal purchases– Policy for source of purchase– Policy for method of purchase

Receipt and storage– Centralized control

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Policies (contd)

Menu Planning– Market trends is observed closely– Meals to meet physiological needs of patients & be palatable– Recipe to be standardized– Selected utensils & equipments used

Forms & Records– Diet chart for special & various diets– Daily records of cost to be maintained

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Policies (contd)

Safety– Employees to be trained to

• extinguish grease fire• report accidents• use of equipments guards• Know the hazards of slippery floors• Carry out waste disposal & understand infectious diseases

Sanitation– Periodic health check ups of employees – Proper handling and disposal of waste

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Sanitation Standards

Continuous education programme for personnelMedical check upsDress standardsCorrect work habitsCleaning and maintenance of equipmentRodent/insect controlClean premisesProper handling and disposal of waste

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Quality Food Production

Menu PlanningFactors affecting menu planningTarget marketing– Profile of the client– Nutritional requirements– Food habits– Meal pattern

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MenuTypes of Menu– Selective (choice)– Non-selective (non-choice)– Single use (for a day)– Cycle Menu (For seasons)

Purchasing & storage methods of purchasing – Informal (open market)– Formal (tender bid)

Quality for different food items is to be set up size, wholesomeness, colour, flavour, maturity etc

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Menu Planning

Cycle Menu- Defined as carefully planned menu which are rotated according to a definite pattern

Advantages– Minimises menu planning time– Coordinating preparation– Reduces repetition of menu items– Promotes standardization of preparation– Increased labour efficiency due to increased coordination – Simplifying purchase– Advantage of purchasing seasonal food– Improved inventory and cost control– Maximises utilisation of equipment

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Advantage of Selective Menu

Improved patient satisfactionImproved variety in menuReduced food wastage

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Advantage of Non-selective Menu

Food and labour costs minised to approx 15%Demand on skill and quantity of labour reduces due to decrease varietyTime is savedStorage and preparation area is reducedQuantity and type of equipment required is reducedReduces supervision

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Equipment & Furnishings

Factors affecting selection of equipment– Need determined by the menu plan complexity of the food

included– Number & types of a patient to be served– Form in which the food will be purchased– Style of service and length of serving period– Number of labor hours available– Abilities of employees to do the work– Accessibility & cost of utilities– Budget & amount of money allotted for equipment– Floor plans and space allotments

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Modernization of Kitchen

Automatic rice pressure cookerAutomatic chapatti makerVegetable choppersMixer-grinderElectrical and gas stoves with multiple burnersRefrigerator- walk in, reach in, under counter reachDish washersSteam sterilizers for sterilizing feeding bottlesMicrowaveDough Maker

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Labour CostLabour represents 50% of total food services cost

Depends on– Use of labour saving equipment– Size and design of work over– Use of disposable or re-useables– Selective or non selective menu– Number of food served– Working condition- temperature, humidity, lighting, noise– Personnel training programme & skills developed– Amount of supervision– Performance standard- employee morale

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Checklist for Cost Control

Cost accountability and budgetingMenu planningPurchasing and receivingLabour efficiencyFood preparation and service Energy efficiencyControl of pilferage

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Identify NeedsIdentify NeedsIdentify NeedsIdentify Needs

Write SpecificationsWrite SpecificationsWrite SpecificationsWrite Specifications

Develop Purchase OrderDevelop Purchase OrderDevelop Purchase OrderDevelop Purchase Order

Informal MethodInformal Method•Price quotationsPrice quotations•Select vendor & place orderSelect vendor & place order

Informal MethodInformal Method•Price quotationsPrice quotations•Select vendor & place orderSelect vendor & place order

Formal MethodFormal Method•Issue bid requestIssue bid request•Tabulate & evaluate bidsTabulate & evaluate bids•Award contractsAward contracts

Formal MethodFormal Method•Issue bid requestIssue bid request•Tabulate & evaluate bidsTabulate & evaluate bids•Award contractsAward contracts

Receiving & Inspection of DeliveriesReceiving & Inspection of Deliveries•Store in proper areaStore in proper area•Evaluate & follow-upEvaluate & follow-up

Receiving & Inspection of DeliveriesReceiving & Inspection of Deliveries•Store in proper areaStore in proper area•Evaluate & follow-upEvaluate & follow-up

Purchasing Process

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Layout of Kitchen Cold Storage

Cold Storage

Dry StoreDry

Store

Dry StoreDry

Store

Janitors Room

Janitors Room

Food Service Supvr

Food Service Supvr

DieticianDietician

Modified DietModified Diet

Preparation

Area

Preparation

Area

Chapatti preparation

Chapatti preparation

Cooking AreaCooking AreaCooking AreaCooking Area

Loading AreaLoading Area

Receiving AreaReceiving Area

Store KeeperStore Keeper

Salad Preparation

Salad Preparation

Washing AreaWashing Area

Trolley Washing Area

Trolley Washing Area

Employee FacilityEmployee Facility

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Functional Flow ChartReceivingReceivingReceivingReceiving

Day StoreDay StoreDay StoreDay StoreCold StoreCold StoreCold StoreCold Store Dry StoreDry StoreDry StoreDry Store

Meat & Veg Meat & Veg cuttingcutting

Meat & Veg Meat & Veg cuttingcutting

Store Keeper’s Office

Store Keeper’s Office Salad, Curd Salad, Curd

DessertsDessertsSalad, Curd Salad, Curd

DessertsDesserts

AttaAttaKneadingKneading

AttaAttaKneadingKneading

Rice, DalRice, DalPickingPicking

Rice, DalRice, DalPickingPicking

Food Service Supvr

Food Service Supvr

DieticianDieticianChapatti PrepChapatti PrepChapatti PrepChapatti Prep

Mod DietMod DietMod DietMod DietUtensilUtensilwashingwashingUtensilUtensilwashingwashing CookingCooking

Rice, DalRice, DalCookingCookingRice, DalRice, Dal

Employee FacilityEmployee Facility

Cooked food Cooked food loading arealoading area

Cooked food Cooked food loading arealoading area

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